Endovascular stent placement in the treatment of upper extremity central venous obstruction in hemodialysis patients

doi:10.1016/S0720-048X(02)00370-4

European Journal of Radiology

Volume 49, Issue 1, January 2004, Pages 81-85

https://doi.org/10.1016/S0720-048X(02)00370-4 Get rights and content

Abstract

Objective: To evaluate the efficacy of stent placement for treating upper extremity central venous obstruction in chronic hemodialysis patients. Methods and Material: Between January 1999 and October 2001, we inserted metallic stents into the upper extremity central veins of 14 patients with shunt dysfunction and/or arm swelling. The indications for stent placement were stenosis or occlusion of the central vein in the upper extremity used for dialysis. Six of the individuals were diagnosed with subclavian vein stenosis, and 5 with brachiocephalic vein stenosis. Of the remaining 3 patients, 2 had subclavian vein occlusion, and 1 had left brachiocephalic vein occlusion. Results: All the stent placement procedures were technically successful, and there were no major complications. Follow-up ranged from 2 weeks to 29 months. The 1-, 3-, 6- and 12-month primary stent patency rates were 92.8, 85.7, 50 and 14.3%, respectively. Repeat interventions, including percutaneous transluminal angioplasty and additional stent placement, were required in 9 patients. The 3-, 6-, 12-month, and 2-year assisted primary stent patency rates were 100, 88.8, 55.5 and 33.3%, respectively. Conclusion: Endovascular stent placement is an effective alternative to surgery in patients with shunt dysfunction due to obstruction of an upper extremity central vein. Repeated interventions are usually required to prolong stent patency.

Introduction

Adequate venous outflow is important for proper function of hemodialysis access in chronic hemodialysis patients. Central venous obstruction in the upper extremity usually occurs secondary to previous subclavian catheter placement procedures, and may lead to dysfunction of the arteriovenous fistula and arm swelling in the affected limb. Angioplasty has been the treatment of choice for venous obstruction. However, a stent must be deployed when results with angioplasty are suboptimal, or when there is rapid restenosis or vessel perforation.

The purpose of this study was to determine the effectiveness of metallic stents for treating subclavian or brachiocephalic venous obstruction in chronic hemodialysis patients with shunt dysfunction.

Section snippets

Methods and material

Between January 1999 and October 2001, 14 chronic hemodialysis patients (6 men and 8 women) with shunt dysfunction due to central venous obstruction were treated with stent placement. The average age in the group was 45 years (range, 16–75 years). Six patients had polytetrafluoroethylene grafts, and 8 had native arteriovenous fistulae.

Based on the indications of arm swelling and/or insufficient hemodialysis, all 14 patients had undergone ipsilateral upper extremity venography. Six of the

Results

All the stent placement procedures were successful (procedural success rate 100%), and there were no major complications such as venous rupture or thrombosis. Early thrombosis (within 2 weeks) occurred in 1 case. In the other 13 patients, follow-up ranged from 4 to 29 months (Table 1). One patient died 5 months after stent placement due to aneurysmal rupture of the arteriovenous fistula. One individual underwent renal transplantation 25 months after the procedure. Four patients were lost to

Discussions and conclusion

Central venous obstruction is one of the most common reasons for shunt dysfunction in chronic hemodialysis patients. In most cases, this problem occurs as a chronic complication of subclavian dialysis catheters used for temporary hemodialysis access [1], [2]. Subclavian or brachiocephalic vein stenosis may cause reduced vascular access flow, increased venous pressure, and subsequent graft thrombosis. These patients usually present with ipsilateral arm swelling and insufficient hemodialysis [3],

References (14)

S. Schwab et al.
Hemodialysis-associated subclavian vein stenosis
Kidney Int.
(1988)
G. Beathard
Percutaneous transvenous angioplasty in the treatment of vascular access stenosis
Kidney Int.
(1992)
E.C. Kovalik et al.
Correction of central venous stenosis: use of angioplasty and vascular Wallstents
Kidney Int.
(1994)
C. Davidson et al.
Mechanisms of angioplasty in hemodialysis fistula stenosis evaluated by intravascular ultrasound
Kidney Int.
(1991)
P.G. Kalman et al.
Management of upper extremity central venous obstruction using interventional radiology
Ann. Vasc. Surg.
(1998)
R. Surrat et al.
The importance of preoperative evaluation of the subclavian vein in dialysis access planning
Am. J. Roentgenol.
(1991)
S. Glanz et al.
Axillary and subclavian vein stenosis: percutaneous angioplasty
Radiology
(1988)

There are more references available in the full text version of this article.

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The outcome of sharp recanalization of chronic central venous occlusions in patients undergoing hemodialysis
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Patients on hemodialysis are particularly vulnerable to central venous occlusion (CVO). Endovascular treatment has gained wide acceptance for the treatment of CVO. However, difficulties in crossing the occluded segment can be encountered during conventional endovascular management. Sharp recanalization has been adopted when conventional endovascular methods could not recanalize the obstructed region. This study aimed to assess the outcome of the sharp venous recanalization technique with angioplasty and stenting in the treatment of CVO in Egyptian patients undergoing hemodialysis.
This retrospective study is based on data from a prospectively maintained department database of patients under regular hemodialysis who underwent the sharp venous recanalization technique for CVO. Routinely, the patients were followed up at 3, 6, and 12 months with a clinical examination. The primary outcomes were technical success and primary patency. Secondary outcomes included complication rates and clinical success.
This study included 40 patients. Thirty-six patients (90%) achieved technical and clinical success. Seven patients (17.5%) had immediate postoperative complications. Four cases had minor complications (10%) and three patients had major complications (7.5%): hemothorax in two patients (5.1%) and pneumothorax in one patient (2.6%). At the 1-year follow-up, reintervention was required in nine patients (22.5%), with primary patency rate of 77.5% and a secondary patency rate of 100%.
Sharp recanalization offers a solution for patients undergoing hemodialysis who developed CVO and failed to be recanalized using the conventional endovascular method. It offered promising technical success, clinical improvement, and good primary patency rates.
Objective Performance Goals Based on a Systematic Review and Meta-Analysis of Clinical Outcomes for Bare-Metal Stents and Percutaneous Transluminal Angioplasty for Hemodialysis-Related Central Venous Obstruction
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To use safety and efficacy outcomes following treatment with percutaneous transluminal angioplasty (PTA) and/or stent placement for thoracic central venous obstruction in hemodialysis-dependent patients to establish objective performance goals (OPGs).
A systematic literature review and meta-analysis were conducted for articles published between January 1, 2000, and August 31, 2021. Efficacy outcomes included primary patency rates at 6 and 12 months, and safety outcomes included adverse events (AEs) categorized as access loss, procedure-related AEs, and serious AEs (SAEs). OPGs were derived from the upper and lower bounds of the 95% confidence intervals for primary patency and SAE rates.
Of 66 articles reviewed, 17 met the inclusion criteria (PTA, n = 4; stent placement, n = 5; PTA/stent, n = 8). The 6- and 12-month primary patency rates for PTA were 50.9% and 36.7%, respectively. Based on these findings, the proposed 6- and 12-month primary patency OPGs identifying superiority against PTA were 66.5% and 52.6%, respectively, and those for noninferiority were 39.0% and 25.7%, respectively. For stent placement, the 6- and 12-month primary patency rates were 69.7% and 47.9%, respectively. The proposed 6- and 12-month primary patency OPGs identifying superiority were 82.1% and 64.1%, respectively, and those for noninferiority were 59.3% and 35.8%, respectively. SAE rates for PTA and stent placement were 3.8% and 8.1%, respectively. Proposed safety OPGs for noninferiority versus superiority for PTA and stent placement were 10.1% versus 1.4% and 13.6% versus 4.8%, respectively.
The OPGs derived from real-world studies of PTA and stent placement may serve as a benchmark for future interventions indicated for this patient population.
Clinical outcomes of endovascular therapy with vascular stents for central venous obstruction in hemodialysis patients
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Citation Excerpt :
It is beneficial for kinked stenosis, elastic recoil after balloon angioplasty, sealing flow-limiting dissection, and maintaining the patency of chronic CVO. However, published reports on the clinical outcomes of stenting for CVO have been limited by the small number of included patients and the relatively old generation of analyzed stents [13–16]. This study aimed to clarify the safety and efficacy of endovascular therapy (EVT) using stents for symptomatic CVO in contemporary practice.
Symptomatic central venous obstruction (CVO) is sometimes observed in patients undergoing hemodialysis. Angioplasty is generally performed for salvage purposes, and stent implantation is performed as a last resort to prevent permanent venous occlusion. However, published reports about the clinical outcomes of stenting for CVO have been limited by the small number of included patients and the relatively old generation of analyzed stents. This study aimed to clarify the safety and efficacy of endovascular therapy (EVT) using stents for symptomatic CVO in contemporary practice.
This retrospective review was performed between May 2012 and August 2021. We retrospectively analyzed consecutive 31 lesions (31 patients, 64 ± 10.7 years old) treated with a vascular stent for elastic recoil after balloon angioplasty or recurrent stenosis <3 months after angioplasty. The primary outcome was primary patency, defined as freedom from target lesion revascularization. The secondary outcome was assisted primary patency, defined as freedom from permanent occlusion of the target stents.
In all cases, stents were successfully deployed on the target lesions. No EVT-related complications were observed. Self-expandable and balloon-expandable stents were used in 26 and 5 lesions, respectively. The median follow-up period was 18 months (interquartile range, 7–40). Kaplan-Meier analysis revealed that the primary patency rates were 66.1 % at 6 months, 61.7 % at 12 months, and 38.4 % at 24 months after EVT. The assisted primary patency rate was 70.3 % 24 months after EVT. In the multivariate analysis, younger age was the only independent predictor of target lesion revascularization (hazard ratio: 0.92, 95 % CI: 0.85–0.99, p = 0.04).
Stent implantation for CVO that is resistant to standard angioplasty seems safe and effective.
A case of pacemaker dysfunction due to interference from a stent placed in the subclavian vein
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A systematic review of venoplasty versus stenting for the treatment of central vein obstruction in ipsilateral hemodialysis access
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Citation Excerpt :
The 6-month APP ranged from 55% to 100% with a pooled APP of 84.10 ± 3.46%. The 12-month stenting APP was reported in eight studies with a total of 213 patients.9,16,17,19,21,23,25,28 In these studies, the APP ranged from 46% to 100%.
This review examines the evidence regarding treatment of central vein obstruction (CVO) in the setting of ipsilateral hemodialysis access. The aim of this work is to identify whether long-term venous patency after central vein stenting is superior compared with balloon venoplasty. To date, there are no evidence-based guidelines to direct the management of CVO in the setting of ipsilateral hemodialysis access.
An extensive systematic database search was performed using Medline, Embase, and the Cochrane Databases to identify all articles published from January 2000 to November 2019 comparing the management of CVO with venoplasty and/or stenting in the setting of ipsilateral hemodialysis access fistulae/grafts.
There were 655 patients with 456 stenoses and 208 occlusions who were treated; 288 underwent venoplasty and 345 underwent stenting. Twenty-two patients failed intervention owing to an inability to traverse the occlusion. The most affected vein was the brachiocephalic vein. A superior primary patency (PP) is noted in those treated with stenting compared with venoplasty in the first 2 years. Overall, both treatments are suboptimal demonstrating a 12-month PP rate of less than 60%. Assisted PP and secondary patency rates were similar for both venoplasty and stenting with a 12-month secondary patency rate of 77.8% to 91.6% for venoplasty and 89.6% to 98.4% for stenting. Periprocedural and long-term complications were rare for both interventions, occurring in 2% of patients.
Although both treatments demonstrated poor patency rates, greater PP is noted for stenting in the first 2 years. Coupled with low complication rates, this finding highlights a potential benefit of stenting as a first-line treatment for CVO. Allowing for the overall poor quality of current studies, even this short-term improvement in PP may benefit patients undergoing hemodialysis. Further research with randomised control trials as well as assessment of adjuvant techniques such as drug-coated stents and balloons, anticoagulant therapy, and the role of intravascular ultrasound use is required.
Left innominate vein stenosis treated with graft replacement with concomitant cardiac surgery
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Left innominate vein stenosis is a serious complication that causes massive venous hypertension and vascular access failure in patients requiring hemodialysis. Percutaneous transluminal angioplasty has been the standard treatment strategy; however, the outcome has been unsatisfactory, with a low primary patency rate. We present the case of a 49-year-old man with symptomatic left innominate vein stenosis that was successfully treated with graft replacement concomitantly with aortic valve replacement via median sternotomy. During surgery, appropriate cardiopulmonary bypass circulation should be established to avoid cerebral venous hypertension, which can cause irreversible brain damage.

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Endovascular stent placement in the treatment of upper extremity central venous obstruction in hemodialysis patients

Abstract

Introduction

Section snippets

Methods and material

Results

Discussions and conclusion

Kidney Int.

Kidney Int.

Kidney Int.

Kidney Int.

Ann. Vasc. Surg.

The importance of preoperative evaluation of the subclavian vein in dialysis access planning

Am. J. Roentgenol.

Axillary and subclavian vein stenosis: percutaneous angioplasty

Radiology